Clinical outcome and changes in gait pattern after pilon fractures

Abstract

Purpose: Axial burst fractures of the distal tibia are challenging to treat and often lead to restricted function of the lower limb. The purpose of this study was to investigate the clinical outcome and changes in gait pattern in such patients.

Methods: Thirty-five patients in a level 1 trauma centre were followed up clinically and by gait analysis. The American Orthopaedic Foot and Ankle Society (AOFAS), visual analogue scale (VAS) foot and ankle scale and Phillips scores were applied. Dynamic pedography (emed-M; Novel, Germany) with analyses of load, pressure and force-time integral were undertaken to investigate possible changes in gait pattern.

Results: Mean follow-up was 50 (19-100) months. Mean AOFAS, VAS foot and ankle and Phillips scores were 65, 63 and 55 points, respectively. There were clear correlations between fracture severity in the Arbeitsgemeinschaft für Osteosynthesefragen (AO) classification and functional outcome in AOFAS (-0.63; p < 0.01), VAS foot and ankle scale (-0.56; p < 0.01) and Phillips (-0.64; p < 0.01) scores. There was a high correlation of 0.74 (p < 0.01) between the severity of the injury in the AO-classification and onset of post-traumatic arthrosis. Dynamic pedography revealed lesser load bearing for the total foot, medial foot, heel, first metatarsal and medial forefoot for the affected limb, and increased load bearing was seen in the lateral midfoot region.

Conclusions: Fractures of the tibial pilon lead to restricted function of the lower limb. Clinical outcome correlates with fracture severity in the AO classification, the onset of post-traumatic arthrosis and changes in gait patterns.

Fig. 1

Distribution of fractures according to the Arbeitsgemeinschaft für Osteosynthesefragen (AO) classification

Fig. 2

Example of a comminuted tibial pilon fracture treated by open reduction and internal fixation (ORIF) in a two-staged protocol. a Computed tomography (CT) after immediate external transfixation shows severe displacement of the articular surface. b Postoperative radiographs after reconstruction using the minimally invasive plate osteosynthesis (MIPO) technique

Fig. 3

Correlations between the three different clinical outcome scores and fracture types according to the Arbeitsgemeinschaft für Osteosynthesefragen (AO) classification. There was a correlation of −0.63 (p < 0.01) with the American Orthopaedic Foot and Ankle Society (AOFAS) score, −0.56 (p < 0.01) with the visual analogue scale (VAS) and −0.64 (p < 0.01) with Phillips score and fracture types according to the AO classification

Fig. 4

Clinical outcome in the three questionnaires in relation to grade of post-traumatic arthrosis using the Kellgren and Lawrence score. There is a deterioration of outcome with arthrosis progression

Fig. 5

Results of dynamic pedobarography. a Maximum loading shows differences under the heel and the first, fourth and fifth metatarsal (MT). b Force-time integral affirms relief under the heel and lateralisation of the gait axis of the injured side

Fig. 6

Example of a pedography after an open C 3.3 pilon fracture on the left side. Relief under the heel, increased loading under the fourth and fifth metatarsals and lateralisation of the gait line is clearly visible